Evaluating the Impact of the WHO’s Safe Childbirth Checklist in Indonesia – A Randomized Controlled Trial

It is recognized that a “one size fits all” checklist would not be feasible for all settings, and the SCC is intentionally not comprehensive. Modification is encouraged to reflect local practice and foster ownership, and may include content changes to specific checklist items or to the qualifying caption boxes. We adapted the pilot edition SCC to the Indonesian context with the help of experts, including paediatricians and gynaecologists, midwives, and more coming from different health facility levels (see Appendix A for the adapted Acehnese pilot edition of SCC).

In treatment sites, the SCC is introduced in the obstetrics unit in the health facilities and is intended for use at four critical junctures in clinical care around the time of birth: on admission of the mother; at the time the mother begins to push (or before caesarean delivery); soon after birth (within one hour); and before discharge. Intervention sites sent their facility representatives to the same information event and participated both in observations and surveys for data collection purposes. Above that, the intervention sites were exposed to four treatment components (i) an introductory event, (ii) provision of the checklist and danger sign information sheets, (iii) inter-facility staff meetings and (iv) monitoring visits. The introductory event consisted of a two hour presentation, explaining the motivation of the checklist and its application, supported by a role play. Moreover, during the event a facility based (non-remunerated) checklist quality coordinator (CQC) was selected, who was responsible for the SCC implementation. Those (iii) CQCs met twice after three and six months after introduction for a two hour focus group discussion including exchange of best practice. (iv) Eleven monitoring visits were carried out over six months, taking each two hours. Those meetings served the provision of new checklists and collection of used checklists, which will ensure adherence to the intervention. Moreover, feedback on previous performance was given and face-to-face interviews with the monitoring team offered the opportunity to ask questions on potential barriers in checklist implementation from both sides.

The control sites participated in an information event, which was designed to inform the facility leadership about the SCC and ask for informed consent. Moreover, for data collection purposes the midwives were exposed to observations as well as the survey on socio-demographic details and perceptions. After selecting comparable sets of facilities via an optimization approach by Schlather & Schneider (2017), comparison facilities were selected via a randomization approach.

2016-10-01

2017-06-01

Our study will primarily focus on the changes in observed behaviour by measuring potential changes in applied essential birth practices between treatment and control group. As we are additionally interested in the interaction with practitioners’ perceptions, further data were collected in individual practitioner surveys addressing the topics (1) quality of care, (2) referral perceptions, (3) working structure, (4) information & communication, (5) knowledge, (6) motivation, (7) empowerment, (8) reminding and (9) the coaching process.

As the checklist is designed to ultimately reduce mortality and morbidity among mothers and children, we also collect data on health outcomes from facilities and use those to construct comparable rates based on delivery numbers. This data is already reported for governmental usage in the majority of health facilities. Here, the quality of the data collection by each Intervention Unit needs to be ensured. If possible it will be tried to follow-up on patient fatality cases after discharge to be able to report postpartum mortality rates adequately. Another important outcome is birth complications, which can lead to short- and long-term morbidities of mother and child. Many checklist items are aiming at minimizing easily preventable conditions, like birth asphyxia, bacterial sepsis, and hypothermia.

The study will be designed as a randomized controlled trial. It will comprise health facilities that are offering delivery services in Aceh Province in the North of Sumatra Island. We will randomly start to implement the SCC together with a checklist specific training in about 50% of the health institutions selected for the study. The checklist will be applied by midwives during standard deliveries for six months. This study design allows us to establish two groups of health facilities (treatment and control group) to causally identify the effect of the intervention on the selected outcomes. If the instrument proves to be effective all participating health facilities will gain access to the instrument.

Using an optimization matching approach by (Schlather & Schneider, 2017), we obtain a counterfactual, which enables a thorough statistical identification of potential treatment effects. Both treatment and control sites contained the same number of facilities. The allocation sequence was randomized at the facility level.

We cluster at the unit of the health facility.

Yes

32 Health Facilities

We plan to interview two thirds of facility staff (~400 persons, based on baseline staffing of around 600 providers) and observe deliveries during one week of facility practice (~240 deliveries, based on a yearly birthload of around 12,000 deliveries).

We sampled 16 facilities in the treatment group and 16 facilities in the control group.